A retrospective analysis of liver resection performed without central venous pressure monitoring.

BACKGROUND: Studies have suggested that blood loss can be reduced during liver resection by monitoring and maintaining low central venous pressure (CVP) through fluid restriction or other means, but such a strategy carries risks to the patient including those inherent to central venous catheterization. We sought to characterize fluid management and blood loss during liver resections done without CVP monitoring. METHODS: Retrospective data were extracted from electronic anesthesia records for 993 liver resections. For 135 resections, between 2011 through 2013, where a documentation template was used that recorded fluid administration prior to hepatic inflow occlusion, multivariate analysis was performed to test for an association between pre-clamp fluid volumes administered and blood loss and other adverse outcomes. RESULTS: The median estimated blood loss was 300 mL and overall rate of transfusion was 8.6%. There was no statistically significant association between crystalloid volume administered prior to inflow clamping (median 900 mL) and blood loss, mortality or length of stay in the subset of patients with supplemental fluid data. CONCLUSION: Liver resection can be performed safely without either CVP monitoring or non-invasive continuous cardiac output monitoring. Additionally, there was no disadvantage to a practical approach to fluid administration prior to inflow clamping during liver resections in the absence of CVP monitoring with regard to blood loss or short-term outcomes.

A survey of anesthesiologists' and nurses' attitudes toward the implementation of an Anesthesia Information Management System on a labor and delivery floor.

BACKGROUND: An anesthesia information management system (AIMS) is most frequently used in the operating room, but not on labor and delivery (L&D). The purpose of this study is to describe the implementation of an AIMS on L&D and the attitudes of practitioners (anesthesiologists and nurses) toward the system. METHODS: The anesthesiology survey focused on satisfaction with the L&D AIMS, comparison of the L&D AIMS with a handwritten anesthesia record, and comparison of the L&D AIMS with the operating room AIMS. The nursing survey focused on nursing satisfaction with the L&D AIMS and comparison of the L&D AIMS with a handwritten anesthesia record. RESULTS: Most anesthesiologists (76%) were satisfied with the L&D AIMS and 73% would not want to revert back to the paper record. However, most anesthesiologists felt the operating room AIMS was either superior or equal to the L&D AIMS. Although few nurses (4%) preferred the anesthesiologists revert back to the handwritten record overall, the nurses were neutral in their assessment of the AIMS. Most of the criticism related to the location of the system; 56% believed it was not in a convenient location and 74% thought the AIMS equipment "got in their way". CONCLUSIONS: Overall, the anesthesiologists and nurses are satisfied with the L&D AIMS and would not want to switch back to a handwritten record. We conclude that AIMS should not be limited to the operating room setting and can successfully be used in L&D.

Production of endothelial nitric oxide synthase (eNOS) over-expressing piglets.

Vascular function, vascular structure, and homeostasis are thought to be regulated in part by nitric oxide (NO) released by endothelial cell nitric oxide synthase (eNOS), and NO released by eNOS plays an important role in modulating metabolism of skeletal and cardiac muscle in health and disease. The pig is an optimal model for human diseases because of the large number of important similarities between the genomic, metabolic and cardiovascular systems of pigs and humans. To gain a better understanding of cardiovascular regulation by eNOS we produced pigs carrying an endogenous eNOS gene driven by a Tie-2 promoter and tagged with a V5 His tag. Nuclear transfer was conducted to create these animals and the effects of two different oocyte activation treatments and two different culture systems were examined. Donor cells were electrically fused to the recipient oocytes. Electrical fusion/activation (1 mM calcium in mannitol: Treatment 1) and electrical fusion (0.1 mM calcium in mannitol)/chemical activation (200 microM Thimerosal for 10 min followed by 8 mM DTT for 30 min: Treatment 2) were used. Embryos were surgically transferred to the oviducts of gilts that exhibited estrus on the day of fusion or the day of transfer. Two cloned transgenic piglets were born from Treatment 1 and low oxygen, and another two from Treatment 2 and normal oxygen. PCR, RT-PCR, Western blotting and immunohistochemistry confirmed that the pigs were transgenic, made message, made the fusion protein and that the fusion protein localized to the endothelial cells of placental vasculature from the conceptuses as did the endogenous eNOS. Thus both activation conditions and culture systems are compatible with development to term. These pigs will serve as the founders for a colony of miniature pigs that will help to elucidate the function of eNOS in regulating muscle metabolism and the cardiorespiratory system.

Elevations of troponin I after interventional cardiac catheterization.

BACKGROUND: Elevation of cardiac troponin I in the serum is a specific marker for myocardial injury. We measured levels of troponin I in the serum in children before and after cardiac catheterization to determine if this procedure was associated with an increase in levels of troponin. METHODS: We enrolled patients under 21 years of age undergoing cardiac catheterization at our institution. A baseline sample of serum was drawn at the start of the procedure. Repeat samples were obtained immediately after, and six hours subsequent to the procedure. All samples were analyzed for cardiac troponin I using the Abbott AxSYM microparticle immunoassay system. Levels were considered normal (0-0.4 ng/ml) or elevated (>0.4 ng/ml). Patients were excluded if the baseline level was elevated. RESULTS: Levels of cardiac troponin I were elevated in the serum from 11 of 14 (79%) cases immediately after the procedure (p < 0.0001), and in 12 of 14 (86%) six hours later (p < 0.0001). Only 2 patients had recognized complications potentially causing myocardial injury. CONCLUSION: Levels of cardiac troponin I increase in the serum in a high proportion of children after cardiac catheterization. These elevations can be observed immediately, and are maintained for at least six hours. Our study suggests that cardiac catheterization, predominantly intervention, is associated with myocardial injury, even in the absence of complications.

Simultaneous transcatheter closure of an atrial septal defect with an amplatzer septal occluder and radiofrequency ablation of an accessory connection.

This report describes the first case of simultaneous transcatheter closure of an atrial septal defect and radiofrequency ablation of an accessory connection. This was performed successfully on an 8-year-old boy and represents an attractive therapeutic alternative to surgical repair in this combination of relatively common cardiac conditions.

Reversal of severe late left ventricular failure after pediatric heart transplantation and possible role of plasmapheresis.

Late acute cardiac graft failure carries a high mortality in adults. Vascular mediators and factors other than classic T-cell-mediated rejection may play a role in this process, and aggressive multimodality therapy may improve survival. We report experience with plasmapheresis in treating late severe acute left ventricular dysfunction in a group of pediatric heart transplant recipients. We retrospectively reviewed clinical records, echocardiograms, hemodynamics, coronary angiograms, biopsy specimens, and treatment regimens for 5 patients with 7 episodes of late-onset severe graft failure who recovered. Plasmapheresis was applied in all cases, in addition to methylprednisolone, cyclophosphamide, lympholytic agents, and aggressive supportive care including mechanical ventilation and hemofiltration. All patients presented with acute severe left ventricular dysfunction 1.4 to 7.9 years (mean 3.6) after orthotopic heart transplantation. Mean shortening fraction at presentation was 13 to 23% (mean 16), initial endomyocardial biopsy specimens were grade 0 to 3B, and immunofluorescence studies were negative. Treatment included plasmapheresis, cyclophosphamide, mechanical ventilation, hemofiltration, and inotropes. Clinical recovery was slow, with 4 to 8 weeks until left ventricular function normalized, and 2.2 to 9.4 (mean 4.6) weeks to hospital discharge. At follow-up (50 to 38 months, mean 24), all are alive. Two patients are well, whereas coronary vasculopathy developed in 3. Thus, survival may improve in patients with late graft failure with low biopsy score and plasmapheresis combined with multimodality therapy.

Instilling a mediation-based conflict resolution culture.

Conflict thrives and grows in the increasingly competitive and uncertain health care environment. Conflict impacts health care organizations' performance in several areas: (1) patient grievances and health plan member disputes; (2) internal employee and management disputes; and (3) payer, provider, and vendor disputes. "Grief Budgets," the hard costs and soft costs due to disputes that are poorly handled and conflicts that are ignored, detract from an organizations health mission and erode its bottom line. This article offers a strategy to solve conflict at an early stage in all three areas, with measurable results that strengthen profits and improve customer service by instilling a mediation-based conflict resolution culture throughout the organization. Mediation is non-adversarial, neutral, proactive, and collaborative. It is also confidential and always protects the future relationship between the parties. The challenge, therefore, is to strategically implant mediation into the health care organization's structure, to intercept and solve conflict early on. The article provides an overview of the steps needed to install a dispute resolution program.

Effects of long-term infusion of prostacyclin on exercise performance in patients with primary pulmonary hypertension.

STUDY OBJECTIVES: To determine whether long-term IV prostacyclin (PGI(2)) use improves exercise capacity in patients with primary pulmonary hypertension (PPH). DESIGN: Cycle ergometry and the 6-min walk was used to evaluate the exercise performance of patients with PPH. The patients underwent serial exercise testing after starting continuous IV PGI(2) and were followed up for 19.5 +/- 7.5 months. Peak work, peak oxygen consumption (f1.gif" BORDER="0">O(2)), peak O(2) pulse, and distance walked in 6 min were used to evaluate performance. BACKGROUND: PPH is characterized by medial hypertrophy and intimal proliferation of the pulmonary arterioles, leading to elevation of pulmonary artery pressure, right ventricular failure, and death. Palliative treatment consists of vasodilators, anticoagulants, cardiac glycosides, diuretics, and transplantation. PGI(2), a potent vasodilator and inhibitor of platelet aggregation, has been used for long-term treatment when conventional therapy has been unsuccessful. PATIENTS: Sixteen patients with PPH (10 women, 6 men; mean age, 24 years). RESULTS: At the initiation of PGI(2), peak work (+/- SD) was 35.5 +/- 11% of predicted; peak f1.gif" BORDER="0">O(2), 39 +/- 10.4%; peak O(2) pulse, 5.0 +/- 1.7 mL/min; and distance on the 6-min walk, 428 +/- 78 feet. At 18 to 27 months, peak work increased to 58.8 +/- 23% of predicted (p = 0.001), peak f1.gif" BORDER="0">O(2) increased to 52 +/- 15% of predicted (p = 0. 02), peak O(2) pulse increased to 7.1 +/- 3.0 mL/beat (p = 0.004), and performance on the 6-min walk increased to 526 +/- 62 feet (p = 0.001). There was a positive correlation between peak f1.gif" BORDER="0">O(2) and peak 6-min walk of 0.6 (p < 0.005) and between peak work and peak 6-min walk of 0.6 (p < 0.005). CONCLUSIONS: Exercise capacity improved in our patients at up to 27 months of follow-up. Exercise testing is helpful in assessing the functional capacity of patients with PPH and may be useful in guiding therapy. Patients who deteriorate while receiving optimal conventional therapy should be considered for IV PGI(2) therapy.

Bidirectional Glenn shunt in association with congenital heart repairs: the 1(1/2) ventricular repair.

BACKGROUND: The bidirectional Glenn shunt has been used to incorporate a smaller tripartite ventricle into the circulation and create pulsatile pulmonary artery flow. We reviewed our operative experience and assessed hemodynamics of the bidirectional Glenn shunt in 1(1/2) ventricular repair or in conjunction with other repairs of congenital heart defects. METHODS: Between 1992 and 1998, 15 patients (mean age, 8.1+/-7.9 years) had bidirectional Glenn shunt in association with repair of congenital heart defects. Eighty-seven percent had at least one previous operation. All patients had simultaneous or previous intracardiac repair and had bidirectional Glenn shunt to volume unload the small right ventricle (group A, n = 7), to unload the poorly functioning right ventricle (group B, n = 2), to redirect superior vena cava-pulmonary venous atrial connection to treat cyanosis (group C, n = 2), or to unload the pulmonary left ventricle for residual intracavitary hypertension in patients with L-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis (group D, n = 4). Intraoperative hemodynamic assessment was done in 2 patients in group A by selective use of inflow occlusion and flow probes. RESULTS: All patients survived. Four patients had successful, concurrent arrhythmia circuit cryoablation for Wolf-Parkinson-White syndrome (n = 1) or atrial reentry tachycardia (n = 3). Superior and inferior vena caval flow averaged 36% and 64% of cardiac output, respectively. Postoperative superior vena caval pressure (n = 13) was 13.7+/-4.0 mm Hg with pulmonary arterial flow pattern contributed by the ventricle in systole (pulsatile) and the superior vena cava in diastole (laminar). CONCLUSIONS: The bidirectional Glenn shunt is an effective adjunct to congenital heart repair to treat pulmonary ventricular pressure-volume problems and anomalous superior vena caval to left atrial connections.

Pediatric coronary artery bypass for Kawasaki congenital, post arterial switch, and iatrogenic lesions.

BACKGROUND: Pediatric coronary artery bypass (PCAB) has been recently employed for expanding indications to treat acquired, congenital, post arterial switch, and other iatrogenic pediatric coronary artery problems. METHODS: Between 1987 and 1998, 3 infants and 13 children (n = 16, mean age 6.1 years, range 2 months-18 years) underwent one or more internal thoracic artery (ITA) to coronary artery (CA) bypass grafts for Kawasaki disease (n = 4), congenital lesions (n = 3), post arterial switch (n = 4), and other iatrogenic obstructions (n = 5). Proximal left main CA arterioplasty was performed concurrently with ITA-CA bypass in 4 patients. RESULTS: Survival is 93.8%. All bypass grafts in surviving patients are patent 2 months-11 years postoperation. The 11 elective patients are well (NYHA I-II). The 5 emergent operations were performed in 2 infants and 3 adolescents who had poor ventricular function prior to ITA-CA bypass due to iatrogenic injuries in 3, congenital critical left main stenosis in 1, and intraoperative iatrogenic coronary injury in 1. The 3 adolescents fared worse, resulting in death in the first, cardiac transplantation in the second, and full recovery in the third. The 2 infants have steadily improving ventricular function. CONCLUSIONS: ITA-CA bypass can be successfully performed in infants and children for expanding elective and life-saving indications with excellent results. Poor preoperative ventricular function often persists, especially in those older children with iatrogenic injuries, and may result in death or cardiac transplantation.

Experimental branch pulmonary artery stenosis angioplasty using a novel cutting balloon.

To determined the safety and efficacy of a bladed balloon in the treatment of branch pulmonary artery stenosis, a model of left pulmonary artery stenosis was surgically created in two-week-old pigs. Seven pigs underwent angioplasty, five with the bladed balloon and two with conventional balloons. Overall, acute results showed a fall in the peak systolic pressure gradients from 8.3 +/- 2.3 mmHg to 3.2 +/- 3.1 mmHg and an increase in the minimum stenotic diameters from 4.5 +/- 2mm to 5.6 +/- mm. Acute pathological examination after cutting angioplasty showed regular luminal cuts that healed completely by four to six weeks in chronically surviving animals. Two of three surviving animals had persistent vessel enlargement at follow-up with one showing little overall change. Cutting balloons are effective in branch pulmonary artery angioplasty and may have clinical applications.

Balloon dilation of severe aortic stenosis in the neonate: comparison of anterograde and retrograde catheter approaches.

OBJECTIVES: We sought to compare anterograde and retrograde balloon dilation of severe aortic valve stenosis in neonates. BACKGROUND: There is a high incidence of iliofemoral artery complications after retrograde balloon dilation of the aortic valve in the neonate. Therefore, a nonarterial technique of catheter access to the aortic valve would be worth exploring. METHODS: Group 1 included 11 consecutive patients (median age 6 days, range 1 to 42; median weight 3.5 kg, range 2.16 to 4.25) undergoing attempted anterograde dilation through a femoral venous approach. Group 2 included 15 patients (median age 3 days, range 1 to 35; median weight 3.4 kg, range 2.5 to 4.4 kg) who underwent attempted retrograde dilation, including 2 in whom attempted anterograde approach had failed. RESULTS: The valve was successfully crossed in 9 of 11 anterograde and 13 of 15 retrograde dilations. In both groups, the peak gradient across the valve decreased significantly (both p = 0.001). On echocardiography, the jet width of the aortic incompetence/ annulus diameter ratio was 0.16 +/- 0.08 (mean +/- SD) after anterograde and 0.51 +/- 0.24 after retrograde dilation (p = 0.03), possibly because of unrecognized valve leaflet perforation. Two patients in group 1 developed persistent, mild mitral insufficiency. Femoral artery thrombosis developed in one patient after anterograde dilation and in eight after retrograde dilation (p = 0.03). CONCLUSIONS: This series demonstrates that an anterograde approach for balloon angioplasty of severe neonatal aortic valve stenosis is feasible, achieves good hemodynamic relief and lessens morbidity compared with retrograde arterial techniques.

Coil embolization of a coronary artery to pulmonary artery fistula from an antegrade approach.

Transcatheter embolization of coronary artery fistulae has become the therapy of choice for this uncommon lesion. We report a case in which transcatheter embolization was performed in a nine-year-old boy with a large fistula originating from the proximal portion of the left anterior descending artery and communicating with the pulmonary artery and the right coronary artery. The fistula was occluded 'antegrade' by cannulating the connection with the pulmonary artery to deliver occluding coils.